Revisional Surgery: Caution!

Jarrod Shapiro, DPM PRESENT Practice Perfect Editor Mountain View Medical & Surgical Associates, Madras, Oregon

For some reason I’ve been seeing quite a few patients who have had surgery from other physicians with unanticipated results. This started me thinking about revisional surgery, an often complex and fascinating undertaking that interests many surgeons. Like the hero swooping in to save the day, the revisional surgeon relieves the pain, disability and deformity of her patient to the cheers of all involved. His magic scalpel makes all that’s wrong in the world right again. Her patient, in such joy that his injury is resolved, goes out and tells all of his friends, and everyone in the community now fills up the office of our hero-surgeon.

All kidding aside, revisional surgery is a very satisfying pursuit.  However, cautions abound when dealing with this type of surgery.  

	Tonight's Premier Lecture is Classification of Lower Extremity Wounds and Foot, Part 1 presented by Lawrence Lavery, DPM, MPH.

 I have a few general rules I abide by whenever approaching a patient who may need revisional surgery:

• Never speak badly about the original surgeon.  I never lay blame to the other surgeon, and I move the conversation away from that doctor. You never know what really happened. Realize that some portion of your patients (hopefully small) will require revisional surgery at some time.  I.E. YOU’RE NOT PERFECT.
• Red Flag: If that patient is seeking a lawsuit against the first doctor, be very careful.  This may be a litigious patient who is seeking out the deepest pockets, and you may become inadvertently involved.
• Understand your patient’s true motivation for surgery.  Are they truly in pain?  Are they seeking disability, time off work, pain medications?
• Understand your patient’s and your own limitations.  For example, I performed a revision on a patient with chronic venous insufficiency and poor skin quality months ago and am still dealing with the dehiscence. 
• Understand why their surgery failed in the first place.  Noncompliance?  Poor procedure choice?  Smoking?  Poor surgical technique?  Infection?

The complexity of revisional surgery comes as much from the patient care aspect as it does from the medical side.  I always counsel my patients extensively about the risks, benefits, and potential complications of their surgery.  I’ll discuss the general risks we all tell our patients preoperatively (pain, infection, numbness, tingling, failure, etc.), but these patients also have specific issues pertinent to revisional surgery.  A few of these topics are listed below.

1. Pain.  I’ve found a greater level of pain is present postoperatively in these patients.  This is due perhaps to the often greater complexity and invasiveness of the procedure necessary to reconstruct the patient.  Perhaps it’s due to the gate theory of pain: the extremity has been “sensitized” to pain at the spinal level by the original procedure.  As such I try to enlist postoperative pain regimens with a longer half-life.  For example, popliteal blocks last up to 30 hours in many patients, eliminating much of the initial pain cycle.  Consider pain pumps or cryotherapy units.
2. Failure risk.  The patient has already been through surgery once (if not more than once) and will be looking for a guarantee.  It is unrealistic for either you or your patient to think that there’s no way the revisional surgery can fail.  Additionally, the tissues have already been violated and may not have the same capacity to heal.  Understanding that there is an increased risk for failure will provide the appropriate level of gravity to the situation, thereby preventing the patient from taking the surgery too lightly.  Better a patient taking your instructions seriously than not listening to you and having another failure.
3. Longer healing time.  As mentioned above, the tissues are not the same as in first setting surgery.  Inflammation and edema, as well as poor tissue stock may lead to increased time to fully heal.  Better to give your patient a longer estimated time frame to heal.  If it heals more quickly than anticipated then great – you’re a hero! 
4. Mutual expectations.  This is true for any surgery, revisional or otherwise.  The surgeon and patient must have the same expectations from the surgery.  If your patient thinks he’s going to run a marathon after surgery while you think they’ll be lucky to walk pain free postop, your patient will be unsatisfied by the result even if they had an acceptable outcome in your eyes.  Honestly inform the patient about your expectations and educate them until they understand.  And be sure your expectations are clear.  Do you tell your bunion patients they’ll be able to walk in high heels after their bunionectomy?  Is that really a legitimate expectation?

Preparation is key when it comes to revisional surgery.  Preparation of both the surgeon and the patient.  Understanding why the original surgery failed, creating a clear plan to revise the pathology, and fully educating the patient preoperatively will help eliminate much of the difficulty involved with revisional surgery.  Good luck on your next revision.

What are you thoughts on Revisional Surgery? Join in on or any number eTalk Topics taking place on PRESENT Podiatry, or create one of your own.

Keep writing in with your thoughts and comments or visit eTalk on PRESENT Podiatry and start or get in on the discussion. We'll see you next week. Best wishes!

Jarrod Shapiro, DPM
PRESENT Practice Perfect Editor
[email protected]

Get a steady stream of all the NEW PRESENT Podiatry eLearning by becoming our Facebook Fan. Effective eLearning and a Colleague Network await you.

GRAND SPONSOR MAJOR SPONSORS